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  • About
  • The Global ETD Search service is a free service for researchers to find electronic theses and dissertations. This service is provided by the Networked Digital Library of Theses and Dissertations.
    Our metadata is collected from universities around the world. If you manage a university/consortium/country archive and want to be added, details can be found on the NDLTD website.
11

Assessment of Public Health Risks Associated with Petrochemical Emissions Surrounding an Oil Refinery

Pulster, Erin L. 01 January 2015 (has links)
Refinery operations have been associated with a wide variety of atmospheric emissions consisting of criteria air pollutants, volatile organic components, hazardous air pollutants as well as other pollutants. With approximately 100 oil refineries in the Wider Caribbean region (WCR), hydrocarbons in this region pose significant environmental and human health risks. One of the oldest and largest refineries in the WCR is the Isla Refineriá, which is located on the island of Curaçao, and has been the basis of historical debates and conflict between the public and the local government over the environmental and human health risks. This research aims to establish baseline levels of ambient petrochemical emissions in Curaçao, specifically polycyclic aromatic hydrocarbons (PAHs), inhalable particulate matter (PM10) and sulfur dioxide (SO2), and to evaluate through comparative literature analysis and recommended public health guidelines the potential health risks in Curaçao. In addition, source elucidation of PAHs was conducted using concentration profiles, distribution profiles, binary diagnostic ratios and factor analysis. Passive air samplers with polyurethane foam collection disks (PAS-PUFs) were deployed in 2011 (n=43) and in 2014 (n=30) to measure ambient PAH concentrations. Ambient PAH concentrations ranged from 1.2 ng/m3 in 2011 and 27.3 to 660.1 ng/m3 in 2014, demonstrating no temporal differences. However, there were highly significant spatial differences, with the samples downwind of the refinery having significantly higher ambient PAH concentrations than those upwind in 2014. Source elucidation revealed the ambient PAHs were dominated by petrogenic emission sources (i.e., refinery) in the 2011 and the 2014 downwind samples, whereas the 2014 upwind locations were equally influenced by both petrogenic (i.e., refinery) and pyrogenic (i.e., vehicle emissions) sources. Available hourly, daily and monthly PM10 and SO2 measurements were downloaded from June 2010 through December 2014 from two local air monitoring stations. Concentrations of both PM10 and SO2 in Curaçao are among the highest reported globally, demonstrating an increasing trend over time and exceed current public health guidelines recommended by local and international agencies. It is plausible that the residents of Curaçao may experience health effects often associated with PM10 and SO2, however the epidemiological evidence is inadequate to infer causality between health effects and long-term exposures. Using the USEPA’s risk analysis methodology the resulting cumulative lifetime cancer risk estimates from PAH inhalation were below the level of concern (1.0 x 10-4). In contrast, by evaluating the potency adjusted concentrations relative to the most toxic compound (benzo[a]pyrene), age class (children and adults) extrapolated and site specific risks indicated levels exceeding the upper bound acceptable risk (1.0 x 10-4) by almost two orders of magnitude suggesting the need for remediation.
12

Protocolo de avaliação de compatibilidade entre a gestão de procedimentos e a complexidade de um sistema sócio-técnico

Sosa González, Santiago January 2012 (has links)
O objetivo principal deste trabalho é apresentar um protocolo para avaliação de compatibilidade entre a gestão de procedimentos e a complexidade do sistema sócio-técnico em que esses são aplicados. Tal protocolo consiste das seguintes etapas: (a) delimitação do sistema sócio-técnico a ser estudado; (b) caracterização do sistema sócio-técnico; (c) caracterização da complexidade do sistema em estudo; (d) aplicação de dois tipos de questionários aos membros do sistema investigado; um deles destinado a avaliar a percepção em relação a um conjunto de princípios acerca de como os procedimentos deveriam ser gerenciados em um sistema complexo; outro destinado a avaliar a percepção acerca da extensão pela qual os princípios realmente são usados; (e) uma reunião de retorno dos resultados da avaliação aos membros do sistema sócio-técnico; (f) elaboração de recomendações para melhorar a gestão de procedimentos. A aplicação do protocolo é ilustrada por meio de um estudo de caso na sala de controle de uma refinaria de petróleo. / The main objective of this dissertation is to introduce a protocol for assessing the compatibility between the procedures management and the complexity of a socio-technical system in which these are applied to. This protocol consist of the following steps: (a) definition of the socio-technical system to be studied, (b) characterization of socio-technical system, (c) characterizing of the system under study complexity, (d) applying two questionnaires of different kinds to the members of the system investigated, one of them to assess the perceptions in relation to a set of principles about how the procedures should be managed in a complex system, and another designed to assess the perception of the extent to which the principles are actually used, (e) carrying out a return meeting of the assessment results to the members of socio-technical system, (f) developing of recommendations to improve management procedures. The application of the protocol is illustrated through a case study in an oil refinery control room.
13

Protocolo de avaliação de compatibilidade entre a gestão de procedimentos e a complexidade de um sistema sócio-técnico

Sosa González, Santiago January 2012 (has links)
O objetivo principal deste trabalho é apresentar um protocolo para avaliação de compatibilidade entre a gestão de procedimentos e a complexidade do sistema sócio-técnico em que esses são aplicados. Tal protocolo consiste das seguintes etapas: (a) delimitação do sistema sócio-técnico a ser estudado; (b) caracterização do sistema sócio-técnico; (c) caracterização da complexidade do sistema em estudo; (d) aplicação de dois tipos de questionários aos membros do sistema investigado; um deles destinado a avaliar a percepção em relação a um conjunto de princípios acerca de como os procedimentos deveriam ser gerenciados em um sistema complexo; outro destinado a avaliar a percepção acerca da extensão pela qual os princípios realmente são usados; (e) uma reunião de retorno dos resultados da avaliação aos membros do sistema sócio-técnico; (f) elaboração de recomendações para melhorar a gestão de procedimentos. A aplicação do protocolo é ilustrada por meio de um estudo de caso na sala de controle de uma refinaria de petróleo. / The main objective of this dissertation is to introduce a protocol for assessing the compatibility between the procedures management and the complexity of a socio-technical system in which these are applied to. This protocol consist of the following steps: (a) definition of the socio-technical system to be studied, (b) characterization of socio-technical system, (c) characterizing of the system under study complexity, (d) applying two questionnaires of different kinds to the members of the system investigated, one of them to assess the perceptions in relation to a set of principles about how the procedures should be managed in a complex system, and another designed to assess the perception of the extent to which the principles are actually used, (e) carrying out a return meeting of the assessment results to the members of socio-technical system, (f) developing of recommendations to improve management procedures. The application of the protocol is illustrated through a case study in an oil refinery control room.
14

Protocolo de avaliação de compatibilidade entre a gestão de procedimentos e a complexidade de um sistema sócio-técnico

Sosa González, Santiago January 2012 (has links)
O objetivo principal deste trabalho é apresentar um protocolo para avaliação de compatibilidade entre a gestão de procedimentos e a complexidade do sistema sócio-técnico em que esses são aplicados. Tal protocolo consiste das seguintes etapas: (a) delimitação do sistema sócio-técnico a ser estudado; (b) caracterização do sistema sócio-técnico; (c) caracterização da complexidade do sistema em estudo; (d) aplicação de dois tipos de questionários aos membros do sistema investigado; um deles destinado a avaliar a percepção em relação a um conjunto de princípios acerca de como os procedimentos deveriam ser gerenciados em um sistema complexo; outro destinado a avaliar a percepção acerca da extensão pela qual os princípios realmente são usados; (e) uma reunião de retorno dos resultados da avaliação aos membros do sistema sócio-técnico; (f) elaboração de recomendações para melhorar a gestão de procedimentos. A aplicação do protocolo é ilustrada por meio de um estudo de caso na sala de controle de uma refinaria de petróleo. / The main objective of this dissertation is to introduce a protocol for assessing the compatibility between the procedures management and the complexity of a socio-technical system in which these are applied to. This protocol consist of the following steps: (a) definition of the socio-technical system to be studied, (b) characterization of socio-technical system, (c) characterizing of the system under study complexity, (d) applying two questionnaires of different kinds to the members of the system investigated, one of them to assess the perceptions in relation to a set of principles about how the procedures should be managed in a complex system, and another designed to assess the perception of the extent to which the principles are actually used, (e) carrying out a return meeting of the assessment results to the members of socio-technical system, (f) developing of recommendations to improve management procedures. The application of the protocol is illustrated through a case study in an oil refinery control room.
15

Otimização do uso de água em refinarias de petróleo. / Optimization of water use in oil refineries.

Michele Anze 26 April 2013 (has links)
As refinarias de petróleo utilizam grandes quantidades de água em seus processos e por isso são impelidas a desenvolver fortes programas de redução de seu consumo. O objetivo do presente estudo é a aplicação de metodologia de otimização em problemas de alocação ótima e reuso de água em refinaria de petróleo. Diferentemente dos enfoques tradicionais que buscam tratar os efluentes gerados para atender às legislações ambientais ou para algum tipo de reuso na planta, a metodologia utilizada avalia os processos que usam água, questionando as causas da geração do efluente. Essa abordagem envolve o levantamento de dados industriais, análise dos processos de produção, identificação de oportunidades para aplicar as estratégias de otimização da alocação de água: racionalização, reuso e/ou reciclagem do efluente e, em seguida, a otimização da rede de água. Visando obter uma rede de água que seja aplicável na indústria, desenvolveu-se um procedimento específico baseado em regras heurísticas que representam as restrições reais dos processos. Através deste procedimento, o consumo de água fresca atingido é próximo do valor ótimo encontrado na literatura. As redes de água geradas são simples, com poucas interconexões e, consequentemente, os investimentos necessários para implementação são menores. / Oil refineries consume a large amount of water in their processes and because of that they are urged to develop strong programs to reduce their water consumption. The aim of this study is to apply an water optimization methodology in an oil refinery. Unlike traditional approaches that only search for treating the effluents in order to meet environmental legislation or to reuse in the plant, this methodology evaluates the processes that use water, questioning the causes of the wastewater generation. This approach involves the industrial data collection, analysis of production processes, identification of opportunities to optimize water use: rationalization, reuse and/or recycling of the effluent and, lastly, the water network optimization. Looking for a water network that is applicable in the industry, in this study it was also developed a specific optimization procedure based on heuristic rules representing the constraints of the actual processes. Through this procedure, freshwater consumption was found to be close to that of the theories found in the literature. The water networks generated are simple, with few interconnections and, consequently, the investments required to implement them are small.
16

Significant energy saving in industrial natural draught furnace: A model-based investigation

Karem, S., Al-Obaidi, Mudhar A.A.R., Alsadaie, S., John, Yakubu M., Mujtaba, Iqbal M. 28 March 2022 (has links)
yes / In all industrial petrochemical plants and refineries, the furnace is the source of heat resulting from fuel combustion with air. The model-based furnace simulation is considered one of the efficient methods help to reduce the energy loss and maintain fixed refinery revenues, conserving energy, and finally reducing external fuel consumption and total fuel cost. In this paper, a model-based simulation is carried out for a natural air draught industrial scale furnace related to Liquified Petroleum Gas (LPG) production plant in Libya to thoroughly investigate the most responsible factors in lowering the furnace butane exit temperature, which is supposed to be two degrees Fahrenheit higher than inlet temperature. Therefore, to resolve this industrial problem, Aspen Hysys V10, coupling with EDR (exchanger design and rating) is used to carry out rigorous model-based simulation. This is specifically used to assess the impact of heat loss from inside the firebox to the surrounding medium and heat loss from the furnace stack and walls, besides the effect of excess air on the furnace efficiency. Furthermore, this research intends to verify whether the operating conditions, such as furnace tubes inlet flow rate, temperature and pumping pressure, are conforming to the upstream process design specifications or need to be adjusted. The results confirm that increasing furnace outlet temperature two degrees Fahrenheit from off specification 190 °F instead of 184 °F is successfully achieved by decreasing upstream stream flowrate 25% below the operating value and cutback excess air gradually until 20%. Also, the results clarify the necessity of increasing the flue gas temperature by 7% over design condition, to gain a significant reduction of heat loss of 31.6% and reach as low as 35.5 MBtu/hr. This improvement is achieved using optimum operating conditions of an excess air of 20%, and flue gas oxygen content of 3.3% delivered to stack. Accordingly, the furnace efficiency has been increased by 18% to hit 58.9%. Furthermore, the heat loss from the furnace walls can be also reduced by 68% from 5.41 MBtu/hr to 1.7 MBtu/hr by increasing the refractory wall thickness to 6 in., which entails an increase in the furnace efficiency by 3.66% to reach 58.96%. Decreasing the heat loss fraction through the refractory wall, pip doors, expansion windows and refractory hair cracks would also increase the efficiency by 21% to reach a high of 59.7%. Accordingly, a significant reduction in daily fuel consumption is observed, which costs 1.7 M$ per year. The outcomes of this research clearly show the potential of reducing the operation and maintenance costs significantly.
17

The Study of Citizen Participation and the Hi-Tech Petrochemical Zone Transformed from China Petroleum Corporation

Tsai, Chin-I 28 August 2006 (has links)
In recent years, ¡§Boost the economy and cut down the unemployment rate¡¨ has become a common understanding of the people in Taiwan, which is the government¡¦s goal for economic development as well. One of the most effective strategies to boost the economy is to encourage investment. However, the rising concern of environmental protection and the consciousness of living peacefully with the mother natural have become a trend nowadays. Furthermore, not only business but also the government and the neighboring residents have increased their standards for environmental protection. Therefore, the industry has tended to be more prudent to any new development project. What deserves to be mentioned is, no matter how wonderful a proposed project is, without the support of local residents, no project can be executed. Therefore, we should regard the citizen participation and environmental impact assessment (EIA). China Petroleum Corporation (CPC) proposed at the end of 2002, aiming to make the transformation from an oil plant to a hi-tech petrochemical zone on Kaohsiung Oil Refinery, with new petrochemical equipment and nono-technology. Ministry of Economic Affairs has agreed with the proposed transformation with the condition that CPC has to obtain approval from the local residents, representatives and government. According to the analysis of power interaction, this study intends to provide related policy suggestions to the government and CPC with the purpose of economic prosperity. For the evolution of modern society, sustainable development and business continuity will play important roles. Besides adopting opinion poll, Delphi Technique is also applied as the research methodology to carry on experts¡¦ interviews and questionnaires investigation.
18

Compost bioremediation of oil sludge by using different manures under laboratory conditions

Ubani, Onyedikachi 06 1900 (has links)
This study was conducted to measure the reduction in polycyclic aromatic hydrocarbons (PAHs) content in oil sludge by co-composting the sludge with pig, cow, horse and poultry manures under laboratory conditions. Four kilograms of soil spiked with 800g of oil sludge was co-composted differently with each manure in a ratio of 2:1 (w/w) spiked soil: manure and wood-chips in a ratio of 2:1 (w/v) spiked soil: wood-chips. Control was set up similar as the one above but without manure. Mixtures were incubated for 10 months at room temperature. Compost piles were turned weekly and moisture level was maintained at between 50% and 70%. Moisture level, pH, temperature, CO2 evolution and oxygen consumption were measured monthly and the ash content at the end of experimentation. Bacteria capable of utilizing PAHs were isolated, purified and characterized by molecular techniques using polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE), amplification of the 16S rDNA gene using the specific primers (16S-P1 PCR and 16S-P2 PCR) and the amplicons were sequenced. Extent of reduction of PAHs was measured using automated soxhlet extractor with Dichloromethane as the extraction solvent coupled with gas chromatography/mass spectrometry (GC/MS). Temperature did not exceed 27.5OC in all compost heaps, pH ranged from 5.5 to 7.8 and CO2 evolution was highest in poultry manure at 18.78μg/dwt/day. Microbial growth and activities were enhanced. Bacteria identified were Bacillus, Arthrobacter and Staphylococcus species. Results from PAH measurements showed reduction between 77 and 99%. The results from the control experiments may be because it was invaded by fungi. Co-composting of spiked soils with animal manures enhanced the reduction in PAHs. Interestingly, all bacteria isolated and identified in this study were present in all treatments, including the control. / Environmental Sciences / M.Sc. (Environmental Sciences)
19

Análise de acidente de trabalho em uma refinaria de petróleo / Work accident analysis in an oil refinery: disagreements between the behavioural and organizational safety

Hurtado, Sandra Lorena Beltran 08 December 2015 (has links)
Introdução - Os acidentes de trabalho nas refinarias de petróleo se destacam por liderar vários indicadores de incidência e mortalidade dentro da indústria de transformação no Brasil. A abordagem das análises dos acidentes tem evoluído desde uma concepção do erro humano até as relações inter organizacionais. As empresas continuam usando abordagens tradicionais na investigação de acidentes que não ajudam na prevenção eficaz dos mesmos. Os estudos aprofundados em acidentes do setor que mostrem a relação de fatores organizacionais são escassos. Em Setembro de 2014, em uma refinaria da região sudeste de Brasil, seis trabalhadores sofreram queimaduras múltiplas como consequência de um incêndio por vazamento de gás liquefeito de petróleo (GLP) que entrou em contato com uma fonte de ignição. Uma das vítimas faleceu dois meses depois. Objetivo - Contribuir para a difusão de uma abordagem organizacional para analisar este acidente de trabalho ultrapassando o erro humano, as causas técnicas e as perspectivas indicadas pelas normas padrão. Método - Os dados empíricos são baseados em um estudo qualitativo de um acidente de trabalho. Para realizar este estudo de caso usamos entrevistas, Análise Coletiva de Trabalho, observação participante e análise de documentos. Em seguida, realizamos uma Análise Organizacional do Evento (AOE) e aplicamos o Modelo de Análise e Prevenção de Acidentes (MAPA). Resultados Para o trabalho que ocasionou o acidente foi trocado o técnico de operação e alguns contratados também eram novos na atividade. Foi utilizado um torquímetro com bomba elétrica, ao invés das ferramentas manuais usadas nas anteriores liberações. A liberação teve inicio três horas antes do recomendado e foi feita sem uma purga completa na linha. Os documentos de análise de risco e de medidas de isolamento da linha foram elaborados com mais de um ano de antecedência. Os treinamentos para os contratados são deficientes. O desligamento do alarmes e a ausência do técnico de segurança durante a liberação concorrem 8 com a falta de treinamento, com a habitualidade de trabalhar sem alguns equipamentos e com a baixa valorização de alarmes. Não existiam reuniões entre os trabalhadores diretos e contratados para discutir os detalhes técnicos da liberação. Não tinha mangueiras do sistema contra incêndio nem rota de fuga durante a abertura do flange. A seleção do operador para liberar a linha de GLP pode ter sido uma estratégia para favorecer a entrega antecipada do projeto. A empresa utiliza um sistema de bonificação por desempenho que termina incentivando os trabalhadores a executar atividades sem cumprimento de todas as normas de segurança. Os trabalhadores de chão de fábrica têm baixa participação na elaboração de novos procedimentos dentro de uma cultura de segurança excessivamente normatizada. Conclusões O acidente tem como origem a interação de fatores sócio organizacionais: entre eles a cultura de segurança excessivamente normatizada, ferramentas de gestão e indicadores de resultado que dão uma sensação de falsa segurança aos gestores, decisão de adiantar o projeto, troca do técnico de operação e gestão de desempenho que estimula a burla de barreiras. / Introduction - Work accidents in oil refineries stand out for leading several incidence and mortality indicators within the manufacturing industry in Brazil. The approach of the analysis of accidents has evolved from a conception of human error to the interorganizational relations. Companies continue to use traditional approaches in the investigation of accidents that do not help in effective prevention. In-depth studies on industry accidents that show the relationship of organizational factors are scarce. On September 2014, in a refinery in the south-eastern region of Brazil, six workers suffered burns multiples as a result of a fire by pouring Liquefied Petroleum Gas (LPG) which came into contact with an ignition source. One of the victims died two months later. Aim - To contribute to the diffusion of an organizational approach to analyzing this work accident beyond human error, technical causes and the prospects indicated by the standard rules. Method - The empirical data are based on a qualitative study of a work accident. This case study used interviews, Collective Labour Analysis, participant observation and document analysis. Then we conducted an event organizational analysis and we applied the Model Analysis and Accident Prevention (MAPA). Results - For work that caused the accident the operation technician was changed and some contractors were also new to the activity. A torque wrench with electric pump was used instead of the hand tools used in previous releases. The release began three hours before recommended and was made without complete purge in the line. Risk analysis and insulation measures documents were designed with more than one year prior. Trainings for contractors are defective. The shutdown of the alarms and the lack of safety technician during the release, competes with the lack of training, with the customary character of work without some equipment and the low valuation of alarms. There were no meetings between direct and contract workers to discuss the technical details of the release. Fire hoses system or escape route during the opening of the flange were inexistent. The 10 operator\'s selection to release the LPG line may have been a strategy to promote early delivery of the project. Company uses a performance evaluation system which ends by encouraging workers to perform activities without complying with all safety standards. The shop floor workers have low participation in the development of new procedures within an overly standardized safety culture. Conclusions - The accident has as its origin the interaction of social and organizational factors including, excessive standardized safety culture, management tools and outcome indicators that give a false sense of safety to managers, decision to advance the project, change of operation technician and performance management that stimulates the habitual non-compliance of some barriers.
20

Análise de acidente de trabalho em uma refinaria de petróleo / Work accident analysis in an oil refinery: disagreements between the behavioural and organizational safety

Sandra Lorena Beltran Hurtado 08 December 2015 (has links)
Introdução - Os acidentes de trabalho nas refinarias de petróleo se destacam por liderar vários indicadores de incidência e mortalidade dentro da indústria de transformação no Brasil. A abordagem das análises dos acidentes tem evoluído desde uma concepção do erro humano até as relações inter organizacionais. As empresas continuam usando abordagens tradicionais na investigação de acidentes que não ajudam na prevenção eficaz dos mesmos. Os estudos aprofundados em acidentes do setor que mostrem a relação de fatores organizacionais são escassos. Em Setembro de 2014, em uma refinaria da região sudeste de Brasil, seis trabalhadores sofreram queimaduras múltiplas como consequência de um incêndio por vazamento de gás liquefeito de petróleo (GLP) que entrou em contato com uma fonte de ignição. Uma das vítimas faleceu dois meses depois. Objetivo - Contribuir para a difusão de uma abordagem organizacional para analisar este acidente de trabalho ultrapassando o erro humano, as causas técnicas e as perspectivas indicadas pelas normas padrão. Método - Os dados empíricos são baseados em um estudo qualitativo de um acidente de trabalho. Para realizar este estudo de caso usamos entrevistas, Análise Coletiva de Trabalho, observação participante e análise de documentos. Em seguida, realizamos uma Análise Organizacional do Evento (AOE) e aplicamos o Modelo de Análise e Prevenção de Acidentes (MAPA). Resultados Para o trabalho que ocasionou o acidente foi trocado o técnico de operação e alguns contratados também eram novos na atividade. Foi utilizado um torquímetro com bomba elétrica, ao invés das ferramentas manuais usadas nas anteriores liberações. A liberação teve inicio três horas antes do recomendado e foi feita sem uma purga completa na linha. Os documentos de análise de risco e de medidas de isolamento da linha foram elaborados com mais de um ano de antecedência. Os treinamentos para os contratados são deficientes. O desligamento do alarmes e a ausência do técnico de segurança durante a liberação concorrem 8 com a falta de treinamento, com a habitualidade de trabalhar sem alguns equipamentos e com a baixa valorização de alarmes. Não existiam reuniões entre os trabalhadores diretos e contratados para discutir os detalhes técnicos da liberação. Não tinha mangueiras do sistema contra incêndio nem rota de fuga durante a abertura do flange. A seleção do operador para liberar a linha de GLP pode ter sido uma estratégia para favorecer a entrega antecipada do projeto. A empresa utiliza um sistema de bonificação por desempenho que termina incentivando os trabalhadores a executar atividades sem cumprimento de todas as normas de segurança. Os trabalhadores de chão de fábrica têm baixa participação na elaboração de novos procedimentos dentro de uma cultura de segurança excessivamente normatizada. Conclusões O acidente tem como origem a interação de fatores sócio organizacionais: entre eles a cultura de segurança excessivamente normatizada, ferramentas de gestão e indicadores de resultado que dão uma sensação de falsa segurança aos gestores, decisão de adiantar o projeto, troca do técnico de operação e gestão de desempenho que estimula a burla de barreiras. / Introduction - Work accidents in oil refineries stand out for leading several incidence and mortality indicators within the manufacturing industry in Brazil. The approach of the analysis of accidents has evolved from a conception of human error to the interorganizational relations. Companies continue to use traditional approaches in the investigation of accidents that do not help in effective prevention. In-depth studies on industry accidents that show the relationship of organizational factors are scarce. On September 2014, in a refinery in the south-eastern region of Brazil, six workers suffered burns multiples as a result of a fire by pouring Liquefied Petroleum Gas (LPG) which came into contact with an ignition source. One of the victims died two months later. Aim - To contribute to the diffusion of an organizational approach to analyzing this work accident beyond human error, technical causes and the prospects indicated by the standard rules. Method - The empirical data are based on a qualitative study of a work accident. This case study used interviews, Collective Labour Analysis, participant observation and document analysis. Then we conducted an event organizational analysis and we applied the Model Analysis and Accident Prevention (MAPA). Results - For work that caused the accident the operation technician was changed and some contractors were also new to the activity. A torque wrench with electric pump was used instead of the hand tools used in previous releases. The release began three hours before recommended and was made without complete purge in the line. Risk analysis and insulation measures documents were designed with more than one year prior. Trainings for contractors are defective. The shutdown of the alarms and the lack of safety technician during the release, competes with the lack of training, with the customary character of work without some equipment and the low valuation of alarms. There were no meetings between direct and contract workers to discuss the technical details of the release. Fire hoses system or escape route during the opening of the flange were inexistent. The 10 operator\'s selection to release the LPG line may have been a strategy to promote early delivery of the project. Company uses a performance evaluation system which ends by encouraging workers to perform activities without complying with all safety standards. The shop floor workers have low participation in the development of new procedures within an overly standardized safety culture. Conclusions - The accident has as its origin the interaction of social and organizational factors including, excessive standardized safety culture, management tools and outcome indicators that give a false sense of safety to managers, decision to advance the project, change of operation technician and performance management that stimulates the habitual non-compliance of some barriers.

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